Please provide your name, address, and electronic signature signifying your agreement to the paragraphs below.

I, the undersigned, residing at the address below, hereby apply for membership/employment with the Sparta Fire Department.  I have been advised and am fully aware that a representative of the department will be conducting a thorough investigation of my background to assist in determining my suitability for this employment.  I realize that while conducting this background investigation, representatives will be making inquiries of the following personal institutions:  Officials and Records Offices at schools which I have attended;  Physicians and/or other persons who may have examined or treated me for any physical or other type illness or injury;  Police and/or Court Records with whom I may have an arrest or conviction record;  Credit Bureaus and/or firms who may have information regarding my credit history, employment history, and/or financial standing:  present and previous employers;  and any other persons who may be able to provide information about me which the department deems necessary.

I hereby authorize and instruct any person or institution in possession of information about me to release same to the Department.  I hereby waive any privileged or right which might otherwise forbid any physician, or other person who has attended me or any other school official, court, policy agency, credit bureau, employer, firm or person, from disclosing to the department any knowledge or information they have concerning me.  I further consent that the Chief of the Department or his/her representative be provided with a copy of any such records concerning me which they may desire.

I hereby give my consent to the Department or it’s designee to perform a test of my blood and/or urine to determine my possible usage of illegal/prohibited substances.

I recognize the right of the Department, in its sole discretion, to treat all sources as confidential, and withhold from me and/or my agent the names of such confidential sources and information obtained there from.